Early Intervention Parent Consent to Use Email

1 Parental Consent to Use E-mail to Exchange Personally Identifiable Information Parent s Name: _____ E-mail Address: _____ Child s Name: _____ _____ At your request, you have chosen to communicate personally identifiable information concerning your child s Early Intervention treatment by e-mail without the use of encryption. Sending personally identifiable information by e-mail has a number of risks that you should be aware of prior to giving your permission. These risks include, but are not limited to, the following: E-mail can be forwarded and stored in electronic and paper format easily without prior knowledge of the Parent . E-mail senders can misaddress an e-mail and personally identifiable information can be sent to incorrect recipients by mistake. E-mail sent over the Internet without encryption is not secure and can be intercepted by unknown third parties.

2 E-mail content can be changed without the knowledge of the sender or receiver. Backup copies of e-mail may still exist even after the sender and receiver have deleted the messages. Employers and online service providers have a right to check e-mail sent through their systems. E-mail can contain harmful viruses and other programs. Parental Acknowledgement and Agreement I acknowledge that I have read and understand the items above which describe the inherent risks of using e-mail to communicate personally identifiable information. Nevertheless, I, _____, authorize _____ whose e-mail address is _____ to communicate with me at my e-mail address, _____, concerning my child s, _____, participation in the Early Intervention Program (EIP), including but not limited to communication regarding service delivery, his/her progress in the EIP and any other related matters.

3 I understand that use of e-mail without encryption presents the risks noted above and may result in an unintended disclosure of such information. (Optional) In addition, I give permission for members of my child s treatment team to communicate personally identifiable information concerning my child with each other using unencrypted e-mail. Early Intervention team members who I give permission to use unencrypted e-mail to communicate with each other about my child include: (1) _____ with the e-mail address _____ (2) _____ with the e-mail address _____ (3) _____ with the e-mail address _____ (4) _____ with the e-mail address _____ (5) _____ with the e-mail address _____ Parent s Signature _____ Date _____